Cedar Ridge Village
Inspection history, citations, penalties and survey trends for this long-term care facility in West Des Moines, Iowa.
- Location
- 8950 Coachlight Drive, West Des Moines, Iowa 50266
- CMS Provider Number
- 165790
- Inspections on file
- 16
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Cedar Ridge Village during CMS and state inspections, most recent first.
A resident was discharged without receiving the required ABN and NOMNC notifications regarding Medicare/Medicaid coverage and potential liability for non-covered services. Staff interviews confirmed that these notifications were not consistently provided, and the facility lacked a formal policy, relying instead on CMS guidelines.
A resident with an anxiety disorder received PRN clonazepam multiple times without staff documenting non-pharmacological interventions attempted prior to administration. The care plan lacked details on the use of anti-anxiety medication and interventions, and the facility had no policy or established process for such documentation until a recent system update.
Two residents prescribed psychotropic medications did not have their care plans updated to reflect new medication orders, monitoring for side effects, or non-pharmacological interventions. The MDS coordinator confirmed omissions in care plan documentation for both an antidepressant and an antianxiety medication.
Staff did not complete accurate assessments or provide timely interventions for two residents with complex medical needs. One resident continued to receive compression hose after the order was discontinued, with inconsistent documentation and confusion among staff about current orders. Another resident with cardiac conditions and on anti-coagulant therapy had chronic bruising that was not properly documented or tracked due to omissions in the initial assessment and unclear staff responsibilities.
A resident with a history of falls and cognitive impairment was observed multiple times in bed without required fall mats, despite care plan directives and recent injury. Staff interviews revealed inconsistent awareness and implementation of fall prevention measures, and documentation of interventions was not reliably completed. The DON confirmed the care plan was not followed, contrary to facility policy.
A resident with multiple cardiac and respiratory conditions did not receive oxygen therapy as ordered, with observations showing the oxygen flow rate set below prescribed levels and periods when oxygen was not administered at all. Staff interviews revealed inconsistent practices in monitoring and adjusting oxygen delivery, leading to a failure in providing safe and appropriate respiratory care.
Staff failed to follow infection prevention protocols for two residents: one with an indwelling catheter did not receive care using required EBP, including the use of gowns and proper disinfection after a spill, and another with respiratory symptoms was not promptly placed in appropriate isolation, resulting in continued participation in group activities while symptomatic. Staff interviews revealed inconsistent understanding and application of infection control policies.
The facility was found to have deficiencies in food storage and labeling practices. Open food items, such as planko crumbs, sugar, pancake mix, and taco shells, were undated and uncovered. Additionally, thawing meat was improperly stored above other food items in the refrigerator, contrary to the facility's policy. The Dietary Manager acknowledged these issues, which violate the facility's Food Receiving and Storage policy.
The dietary staff at the facility failed to properly execute the pureed food process for residents requiring a pureed diet. A cook was observed pureeing meals without measuring ingredients or using the correct scoop size, and admitted to not being trained on the process. The VP of Culinary stated that staff should follow specific recipes and use a graph to determine scoop size if changes are made, as per facility policy.
Failure to Provide Required Beneficiary Notifications at Discharge
Penalty
Summary
The facility failed to provide required beneficiary notifications regarding Medicaid/Medicare coverage and potential liability for non-covered services to a resident upon discharge. Specifically, clinical record review showed that a resident who was admitted and later discharged did not receive the Advanced Beneficiary Notification (ABN) or the Notice of Medicare Non-Coverage (NOMNC) as mandated by federal regulations. When surveyors requested documentation, the facility was unable to produce the required notifications for this resident, although notifications for two other residents were provided. Interviews with facility staff revealed that the Social Services Coordinator, who was newly hired, discovered the missing notifications while auditing previous work. She confirmed that the required notifications had not been given to some residents at discharge. The DON acknowledged awareness of the missing notifications but stated that overseeing this process was not within his responsibilities. The facility administrator reported that there was no formal policy on ABN/NOMNC notifications, but that the facility follows CMS guidelines.
Failure to Document Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
Facility staff failed to document non-pharmacological interventions attempted prior to administering anti-anxiety (AA) medication to a resident diagnosed with anxiety disorder. The resident was admitted with a diagnosis of anxiety disorder and was prescribed clonazepam 0.5 mg every 8 hours as needed. Over the course of two months, the medication was administered multiple times, but the clinical record and Medication Administration Record (MAR) lacked documentation of non-pharmacological interventions attempted before each administration. The resident's care plan did not include information about the use of AA medication or the non-pharmacological interventions used or attempted prior to administration. Interviews with staff revealed that, until recently, there was no process in place for documenting non-pharmacological interventions prior to PRN AA medication administration. The electronic MAR system had only recently been updated to prompt staff to document such interventions, but prior to this update, no documentation was required or completed. Additionally, the Director of Nursing confirmed that the facility did not have a policy regarding psychotropic medication use and non-pharmacological interventions.
Failure to Update Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for two residents who were prescribed psychotropic medications. For one resident, the care plan initiated did not document the use of an antidepressant or provide directives for staff regarding monitoring for medication side effects, despite physician orders indicating the resident was started on Lexapro for depression. The MDS coordinator confirmed that the antidepressant was not added back to the care plan after the resident returned from the hospital and the medication was prescribed. For another resident with diagnoses of anxiety disorder and depression, the care plan was missing information about the use of an antianxiety medication, non-pharmacological interventions attempted prior to administration, and monitoring for side effects or symptoms related to the medication. The resident's order summary showed a PRN order for clonazepam for anxiety, but this was not reflected in the care plan. The MDS coordinator acknowledged that the antianxiety medication was not listed in the care plan at the time of review.
Failure to Complete Accurate Assessments and Provide Timely Interventions for Residents with Edema and Skin Conditions
Penalty
Summary
Staff failed to appropriately complete resident assessments and provide timely interventions for two residents with significant medical needs. For one resident with a history of coronary artery disease, hypertension, heart failure, localized edema, and acute respiratory failure, the care plan did not document the use of compression hose as ordered. Despite a physician's order discontinuing the use of compression hose, staff continued to apply them, and there was confusion among staff regarding whether the resident should be wearing them. Documentation in the electronic health record and medication administration record was inconsistent, with staff unsure about current orders and responsibilities for monitoring and documenting the use of compression hose. For another resident with multiple cardiac diagnoses and long-term use of anti-coagulant therapy, the initial assessment failed to document the presence of purpura or chronic bruising on the forearms and hands. The care plan instructed staff to monitor for bruising due to anti-coagulant use, but there was no ongoing documentation of bruising in the medication administration record or nursing progress notes after the initial mention. Staff interviews revealed a lack of clarity regarding who was responsible for tracking and documenting the bruising, and the initial assessment's omission led to the absence of a tracking task for this condition. Both deficiencies were identified through clinical record review, observations, resident and staff interviews, and policy review. The findings indicate that the facility did not ensure accurate and complete assessments or timely interventions according to physician orders and resident needs, resulting in lapses in care planning, documentation, and monitoring for residents with complex medical conditions.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain care planned interventions to prevent and mitigate falls for a resident with a history of falls and significant cognitive impairment. The resident, who had diagnoses including atrial fibrillation, stroke, a displaced fracture of the right femur, and senile degeneration of the brain, was care planned to have fall mats on both sides of the bed, the bed in the lowest position, non-skid footwear, and a clutter-free environment. Despite these documented interventions, multiple direct observations revealed that the resident was in bed without fall mats in place on several occasions. Staff members, including a registered nurse and certified nurse aides, did not consistently recognize or implement the requirement for fall mats, and documentation in the electronic health record was not reliably completed to confirm that interventions were in place. Interviews with staff indicated a lack of awareness or understanding of the resident's care plan requirements, with some staff unaware that fall mats were needed and others confirming that documentation of interventions was expected but not always performed. The Director of Nursing acknowledged that the care plan was not being followed and expressed concern about the potential for harm, especially given the resident's recent femur fracture. Review of facility policy confirmed that the nursing team is responsible for communicating and implementing fall prevention interventions for residents with a history of falls.
Failure to Ensure Safe and Accurate Oxygen Therapy Delivery
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for a resident with significant cardiac and respiratory diagnoses, including coronary artery disease, heart failure, and acute respiratory failure with hypoxia. The resident's care plan and physician's orders specified continuous oxygen therapy at 2-3 liters via nasal cannula to maintain oxygen saturation above 88%. However, multiple observations revealed that the oxygen concentrator was set below the ordered range, at 1 1/2 and 1 3/4 liters, and at one point, the resident was found without oxygen, with both the concentrator and portable tank turned off and the tubing stored away. The resident had to request staff assistance to have her oxygen reapplied. Staff interviews indicated a lack of clarity and consistency in following the oxygen therapy orders. A CNA reported that she only turns the oxygen on or off and does not adjust the flow rate, while an RN initially believed the oxygen was set correctly but, upon closer inspection, found it was below the ordered rate and adjusted it. These actions and inactions resulted in the resident not receiving oxygen therapy as ordered, constituting a failure to provide safe and appropriate respiratory care.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and droplet/contact precautions. For one resident with obstructive uropathy and an indwelling catheter, staff did not follow EBP guidelines as outlined in the care plan and facility policy. During an observed catheter care procedure, the certified nursing assistant (CNA) wore gloves but did not don a gown as required. Additionally, after urine was spilled on the floor, the CNA cleaned the area with a paper towel instead of using an appropriate disinfectant, contrary to the infection preventionist's expectations and facility policy. Staff interviews revealed inconsistent understanding and application of EBP protocols. One CNA believed EBP was only necessary for residents with certain infections like influenza, COVID, or C. difficile, while another stated she would use a gown and gloves for catheter care if an EBP sign was posted. The infection preventionist clarified that a gown and gloves should always be used for catheter care and that contaminated surfaces must be disinfected with approved wipes, not just wiped with a paper towel. In a separate incident, another resident with respiratory symptoms and a diagnosis of Parainfluenza Type 2 was not placed in transmission-based precautions (TBP) until after returning from the emergency department, despite having symptoms for several days. Staff interviews indicated a lack of clarity regarding when to initiate isolation and which type of precautions to use. The care plan was not updated to reflect the resident's symptoms or need for TBP until after the diagnosis was confirmed, and the resident continued to participate in communal dining while symptomatic.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. In the main kitchen, several open food items, including a 25-pound bag of planko crumbs, a 25-pound bag of sugar, two boxes of pancake mix, and packages of hard and soft taco shells, were found undated and uncovered. Additionally, a tray of frozen meat was improperly stored on a middle shelf in the walk-in refrigerator, thawing above a pie, which violates the facility's policy of storing thawing meat separately and on the bottom shelf to prevent cross-contamination. During an interview, the Dietary Manager acknowledged the expectation that dry food should be stored in sealed containers and that open food should be sealed, labeled, and dated. The facility's Food Receiving and Storage policy, revised in October 2018, requires dry foods to be removed from original packaging, labeled, and dated, and mandates that uncooked and raw animal products be stored separately in drip-proof containers below fruits, vegetables, and other ready-to-eat foods. The policy also specifies that opened containers must be dated and sealed or covered during storage.
Deficiency in Pureed Food Preparation Process
Penalty
Summary
The facility's dietary staff failed to properly execute the pureed food process for three residents requiring a pureed diet. During an observation, a cook, identified as Staff A, was seen pureeing chicken fried steak, corn, and strawberry shortcake without measuring the ingredients or using the appropriate scoop size as per the facility's guidelines. Staff A admitted to not being trained on the puree process and was uncertain about the correct scoop size to use for serving the residents. In an interview, Staff B, the VP of Culinary, stated that kitchen staff are expected to follow specific recipes from [NAME] Brothers, which include exact measurements for food, fluids, and thickeners, as well as the correct scoop size for serving. Staff B emphasized that if any changes are made to the recipe, the graph should be used to determine the appropriate scoop size, and the serving staff should be informed of any changes. The facility's policy on Appealing Pureed Foods also documented the need to follow the correct amounts of food as noted in the recipe.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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